Pines Palm Dental — Eligibility & Benefits

Sarah M. Johnson

DOB 04/12/1988 · Member ID MRD-88213470 · Meridian Dental PPO

✓ Verified moments ago · Subscriber: self · In-Network

ACTIVE COVERAGE

✓ Deductible satisfied

Patient pays coinsurance only — the $50 annual deductible is fully met.

$1,180 of $1,500 available

79% of the annual maximum remains for this benefit year.

Cleaning due

Last prophylaxis 03/04/2026 — next eligible 09/04/2026 (2 per year).

Annual Maximum

$1,180 / $1,500

$320 used · resets 01/01/2027

Deductible (Individual)

$50 met

Family $150 · $100 met

Orthodontic Lifetime Max

$1,000 / $1,000

$0 used · 50% coinsurance

Plan Details

Carrier

Meridian Dental

Plan Type

PPO

Group

#GRP-4471 · Acme Corp

Network Status

In-Network

Effective Date

01/01/2023

Benefit Year

Calendar Year

Coordination

Primary

Waiting Periods

Major / Ortho only

Coverage by Category

Category	Coverage	Deductible Applies	Waiting Period
Preventive & Diagnostic	100%	No	None
Basic Services	80%	Yes	None
Major Services	50%	Yes	12 months
Orthodontics (child)	50%	No	12 months

Procedure Detail (CDT)

Code	Description	Coverage	Frequency	Last Service	Next Eligible	Est. Patient
D0120	Periodic oral evaluation	100%	2 / year	03/04/2026	09/04/2026	$0
D1110	Prophylaxis — adult cleaning	100%	2 / year	03/04/2026	09/04/2026	$0
D0274	Bitewings — four films	100%	1 / year	09/10/2025	Eligible now	$0
D0210	Complete series radiographs	100%	1 / 3 yrs	—	Eligible now	$0
D2392	Resin composite — 2 surf, posterior	80%	—	01/22/2026	Eligible now	~$38
D2740	Crown — porcelain / ceramic	50%	1 / 5 yrs per tooth	—	Eligible now	~$525
D2950	Core buildup, including pins	50%	1 / 5 yrs per tooth	—	Eligible now	~$95
D3310	Endodontic therapy — anterior	50%	1 / lifetime per tooth	—	Eligible now	~$340
D4341	Perio scaling & root planing / quad	80%	1 / 24 mo per quad	—	Eligible now	~$52
D7140	Extraction — erupted tooth	80%	—	—	Eligible now	~$34
D6010	Surgical implant placement	Not covered	—	—	—	Full fee

Limitations & Notes

› Posterior composite fillings (D2392/D2393) are downgraded to amalgam fee; patient responsible for the difference.

› Missing tooth clause applies to bridges and implants for teeth extracted prior to coverage effective date.

› Sealants (D1351) covered to age 16, permanent molars only.

› Night guards (D9944) covered 50%, 1 per 3 years, pre-authorization required.

› Orthodontics for dependent children only; not available for the subscriber.

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Recent Service History

Date	Code	Description	Billed	Plan Paid	Status
03/04/2026	D1110	Adult cleaning	$105	$105	Paid
03/04/2026	D0120	Periodic exam	$62	$62	Paid
01/22/2026	D2392	Composite filling	$190	$152	Paid
09/10/2025	D0274	Bitewings x4	$68	$68	Paid

Pines Palm Dental · Eligibility & Benefits · retrieved automatically from the carrier portal